LAUSR

Isolated upper extremity motor monoparesis is a wellknown, but rare stroke manifestation. It is often mistaken for other causes of weakness, mostly peripheral nerve pathology [1–4]. When combined with long-lasting thoracic surgery, the first thing that comes to mind is a brachial plexus lesion [5]. We would like to present a case of a patient who suffered a stroke with pure motor right arm monoparesis during thoracic surgery. A 64-year-old man with previously known right lung adenocarcinoma was admitted to the Department of Thoracic Surgery due to cancer recurrence after initial right upper lobectomy. This time, he underwent a right thoracotomy with total right pulmectomy. The operation lasted for 5 h during which his right arm was lifted above his head, and it ended without complications. When he awoke from general anaesthesia in the intensive care unit, isolated right upper extremity weakness was noticed. He did not seem to have any other neurological deficits. His general medical history was negative for hypertension, diabetes and cardiac arrhythmias. His initial neurological evaluation showed pure motor weakness of the entire right upper extremity (manual muscle testing 1/5), normal speech, no cranial nerve lesions, no sensory deficits and no weakness in other extremities. Deep tendon reflexes were symmetrical, except for a slightly diminished right m. brachioradialis reflex. Babinski sign was negative bilaterally. An emergency brain computed tomography showed no pathology, and it was presumed that the isolated weakness of the upper right extremity was a consequence of brachial plexus injury due to long-lasting straining during arm elevation. After 5 days, electromyography (EMG) and nerve conduction study (NCS) of the upper extremities were done, together with neurological re-evaluation. The patient showed no changes compared to the initial status. EMG showed no signs of spontaneous or intentional activity in the analysed muscles of the right upper extremity due to flaccid paresis, with NCS (bilateral median, ulnar, radial, axillary, musculocutaneous and suprascapular nerve testing) within the normal range. On the tenth day following surgery, a brain magnetic resonance imaging (MRI) was done, showing areas of early subacute ischaemia in the perirolandic region, deep vascular territory and at high convexity of the posteromedial part of the left parietal lobe (Fig. 1). This was followed with carotid and vertebral Doppler ultrasonography, which showed a soft plaque in the left carotid bifurcation with no significant stenosis, and a mixed atherosclerotic plaque in the middle portion of the right internal carotid artery that caused luminal stenosis of less than 50%. Electrocardiography showed no signs of cardiac arrhythmia. The patient was started on antiaggregation and hypolipemic therapy, and early physical therapy was initiated. The follow-up evaluation was performed 2 weeks postoperatively and showed a very good improvement of the right arm and forearm weakness, but with a persistent pronounced right hand weakness. Pure motor monoparesis of the upper extremity is a rare manifestation of stroke, usually located in the cortical part of the precentral gyrus, better known as the “hand knob area” [1–4]. This type of stroke represents approximately 1% of all ischaemic strokes [1, 3, 4]. The majority of research shows that precentral gyrus infarctions cause distal-dominant or only distal weakness of the upper extremity [1, 2]. Additionally, it is also documented that subcortical infarctions * Ivana Jurjević [email protected]